MLoadman
New
I chose F10.14 as one of the secondary diagnoses according to the medical record shown below. The answer key showed F10.24 associated with alcohol dependence.
">MEDICAL RECORD
OFFICE - ESTABLISHED
CARDIOLOGY
SEX: MALE
AGE: 83
Date: 01/01/20XX
CHIEF CONCERN: He is here for hospital followup.
PROBLEM LIST:
1. Patient was hospitalized two weeks ago for heart failure, hypertension, ischemic cardiomyopathy.
2. History of progressive weakness.
3. Chronic atrial fibrillation (20XX).
4. Hypertension.
5. Congestive heart failure, secondary to restrictive cardiomyopathy from severe left ventricular hypertrophy.
6. Sick sinus syndrome 9 years S/P VVI pacemaker implant, with generator replacement 2 years ago.
7. Four months S/P acute urinary retention, requiring catheter drainage for 1 week, followed by his physician.
ALLERGIES: No known drug allergies.
MEDICATIONS:
Coumadin 2.5 mg q.d. or AD
Lasix 40 mg q.d.
Levothyroxine 75 mcg 1 tab q.d.
Folic acid 1 mg q.d.
Lisinopril 10 mg q.d.
Carvedilol 3.125 mg b.i.d.
Restoril 30 mg q.h.s. Alprazolam 0.5 mg q.d.
KCl 20 mEq q.d.
Oxygen 3 liters (not regularly)
Thiamine 100 mg q.d.
INTERVAL HISTORY:
The patient presents to our office today for hospital follow up. Two weeks ago, he was admitted for increasing weakness, shortness of breath, and chest palpitations. He was found to have congestive heart failure and was treated with Lasix. He lost approximately 13 pounds during the hospital stay with dramatic improvement in peripheral edema. He was started on Lovenox. A CT scan was negative for pulmonary emboli. Negative Lexiscan was completed. Follow up chest x-ray showed improved pulmonary vascular congestion and he was discharged home.
He continues to feel somewhat weak and tired, but no shortness of breath. His weight has remained stable following discharge. He has a productive cough of tan-to-yellow sputum. He reports this is stable over many years. Low-dose Coreg was started while hospitalized for his chronic atrial fibrillation rate control.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 266 lbs. BP 152/78 in the left arm. Pulse is 80 and regular, oxygen saturation is 93% on room air.
CONSTITUTIONAL: He has a flat affect
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: He has expiratory wheeze in the right middle and right upper lobe.
CARDIOVASCULAR: Neck veins are not clearly elevated. S1, S2 is irregular. No murmurs. He has trace lower extremity edema only.
GASTROINTESTINAL: Abdomen: Protuberant. No edema of the anterior abdominal wall. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.
ASSESSMENT:
1. Recent hospitalization for chronic atrial fibrillation and congestive heart failure.
2. Ongoing excessive alcohol abuse, causing mood disorder.
3. Presence of pacemaker
4. Coumadin daily
PLAN:
1. Increase Coreg to 6.25 mg b.i.d.
2. Office visit in two weeks.
3. Will need to order Holter monitor when heart rate is felt to be controlled.
4. CMP, CBC and TSH just before next office visit
5. Chest x-ray to further evaluate noted wheezes.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
">MEDICAL RECORD
OFFICE - ESTABLISHED
CARDIOLOGY
SEX: MALE
AGE: 83
Date: 01/01/20XX
CHIEF CONCERN: He is here for hospital followup.
PROBLEM LIST:
1. Patient was hospitalized two weeks ago for heart failure, hypertension, ischemic cardiomyopathy.
2. History of progressive weakness.
3. Chronic atrial fibrillation (20XX).
4. Hypertension.
5. Congestive heart failure, secondary to restrictive cardiomyopathy from severe left ventricular hypertrophy.
6. Sick sinus syndrome 9 years S/P VVI pacemaker implant, with generator replacement 2 years ago.
7. Four months S/P acute urinary retention, requiring catheter drainage for 1 week, followed by his physician.
ALLERGIES: No known drug allergies.
MEDICATIONS:
Coumadin 2.5 mg q.d. or AD
Lasix 40 mg q.d.
Levothyroxine 75 mcg 1 tab q.d.
Folic acid 1 mg q.d.
Lisinopril 10 mg q.d.
Carvedilol 3.125 mg b.i.d.
Restoril 30 mg q.h.s. Alprazolam 0.5 mg q.d.
KCl 20 mEq q.d.
Oxygen 3 liters (not regularly)
Thiamine 100 mg q.d.
INTERVAL HISTORY:
The patient presents to our office today for hospital follow up. Two weeks ago, he was admitted for increasing weakness, shortness of breath, and chest palpitations. He was found to have congestive heart failure and was treated with Lasix. He lost approximately 13 pounds during the hospital stay with dramatic improvement in peripheral edema. He was started on Lovenox. A CT scan was negative for pulmonary emboli. Negative Lexiscan was completed. Follow up chest x-ray showed improved pulmonary vascular congestion and he was discharged home.
He continues to feel somewhat weak and tired, but no shortness of breath. His weight has remained stable following discharge. He has a productive cough of tan-to-yellow sputum. He reports this is stable over many years. Low-dose Coreg was started while hospitalized for his chronic atrial fibrillation rate control.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 266 lbs. BP 152/78 in the left arm. Pulse is 80 and regular, oxygen saturation is 93% on room air.
CONSTITUTIONAL: He has a flat affect
HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.
RESPIRATORY: He has expiratory wheeze in the right middle and right upper lobe.
CARDIOVASCULAR: Neck veins are not clearly elevated. S1, S2 is irregular. No murmurs. He has trace lower extremity edema only.
GASTROINTESTINAL: Abdomen: Protuberant. No edema of the anterior abdominal wall. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.
SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.
NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.
ASSESSMENT:
1. Recent hospitalization for chronic atrial fibrillation and congestive heart failure.
2. Ongoing excessive alcohol abuse, causing mood disorder.
3. Presence of pacemaker
4. Coumadin daily
PLAN:
1. Increase Coreg to 6.25 mg b.i.d.
2. Office visit in two weeks.
3. Will need to order Holter monitor when heart rate is felt to be controlled.
4. CMP, CBC and TSH just before next office visit
5. Chest x-ray to further evaluate noted wheezes.
Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
